complaint·September 29, 2023

9099C-1... ** T his page was amended on 10/4/23 to include additional information from the MAR that was provided to the Department during the investigation and to note that a separate citation will be issued on a 809 report, dated 10/4/23, for the following substantiated allegation. A new signature was also obtained ** Allegation: Staff mismanaged resident’s medication. Complaint alleges that (3) bottles of Galantamine (30 pills each) were filled and dropped off 3/17/23 at the facility. On 4/22/23, (R1's) family member was notified by staff that this medication was out and needed to be refilled. (R1's) family member confirmed with the pharmacy that the medication was last filled on 3/17/23 for a quantity of 90 pills and was told that the facility would determine where the missing pills were. (R1's) family members stated the Administrator during this time stated she was not aware of the situation and could not provide a resolution, and the facility “guessed” that the medication accidentally was assigned to another patient when (R1) was moved to that patients room and the medication was accidentally destroyed because the other patient was no longer at the facility. RCC stated on 5/12/23 that before the prior Administrator left the community, (S1) Med-Tech, called the family and said the facility was missing a bottle of medication for her Dementia. RCC confirmed the missing medication was Galantamine and (S1) claimed the bottle was missing, and the February bottle was at home for a while since it was a 90-day supply. RCC explained that (R1's) health care provider said the February bottle/medication was delivered to the family member's house. Both family members who were interviewed confirmed that (R1) never received the medication (3 bottles) with one member stating “she (R1) never got any of the 90-day medications, asserting they "disappeared"., and stated her father, had some supply of the same medication, same dosage, at his residence at another location. MAR for February 2023 and March 2023 appear to have staff initials in each box, as for other medications given on the same day and time (am); however, entries on 3/4 through 3/17 appear to also have a circle around them for the medication, Galantamine. There are no entries on the April 2023 MAR for Galantamine from 4/1- 4/7 or on 4/15 and 4/16, and for (2) other scheduled medications on these same days; there is an entry on 4/1 and 4/2 only for the medication, Tamsulosin, that it was administered in the morning. The MAR for May 2023 has entries on all days for Galantamine, except for on 5/13 and 5/14, which was also observed for medications, Losartan and Lovastatin. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. NOTE: A separate citation was not initially issued on 9/29/23 but is being issued on a separate report, dated 10/4/23 . cont on 9099C2... 9099C-2.. ** This page was amended on 10/4/23 to correctly state information regarding the MAR. This page was amended again on 10/5/23 due to the added information being inadvertently pasted in the middle of an unrelated sentence from the prior report** Allegation: Staff did not ensure that resident received their medication . On 4/22/23, (R1's) family member was notified by staff that this medication was out and needed to be refilled. (R1's) family member confirmed with the pharmacy that the medication was last filled on 3/17/23 for a quantity of 90 pills and was told that the facility would determine where the missing pills were. One family member stated that as of the day of the meeting, 5/2/23, she and family were never notified of the missing meds and (R1) did not receive this medication for several weeks. RCC stated on 5/12/23 "yes, there were (3) days of missed medications" and confirmed that the facility does use a MAR. LPA was provided with copies of MAR documentation from Jan 2023- May 2023, as requested. MAR for February 2023 and March 2023 appear to have staff initials in each box, as for other medications given on the same day and time (am); however, entries on 3/4 through 3/17 appear to also have a circle around them for the medication, Galantamine. There are no entries on the April 2023 MAR for Galantamine from 4/1- 4/7 or on 4/15 and 4/16, and for (2) other scheduled medications on these same days; there is an entry on 4/1 and 4/2 only for the medication, Tamsulosin, that it was administered in the morning. The MAR for May 2023 has entries on all days for Galantamine, except for on 5/13 and 5/14, which was also observed for medications, Losartan and Lovastatin. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not effectively communicate with resident’s family. Complaint states that on 4/26/23, (R1) was taken by a non-emergency ambulance provider to the ER and resident’s family was not aware until the following morning when resident’s granddaughter visited and noticed a hospital admittance band on (R1’s) wrist . One family member stated that no staff told her or her sister that (R1) had gone to the hospital. A second family member stated “staff said they tried calling all of us but they did not leave any messages when (R1) was sent to the hospital”. One member asserted that (R1) did not have a stomachache and was sent to the hospital they sent her to since it is a trauma center and (R1) hit her head. RCC stated on 5/12/23 that the facility documents when they contact residents' family members or POA in their charting notes. There were no charting notes available from 4/26/23 or 4/27/23. The Administrator at the time was not able to be interviewed. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C-3... 9099C-3... ** This page was amended on 10/4/23 to note that a separate citation was not initially issued for this substantiated allegation but is being issued on a separate report, dated 10/4/23** Allegation: Staff misinformed resident’s family about resident’s hospitalization. Allegation states that when (R1’s) family member visited (R1) on the morning of 4/27/23, she observed her to be wearing a hospital bracelet from 4/26/23, from another hospital than resident’s primary assigned one. When (R1’s) family inquired about the ER visit, they were told by facility staff (R1) had been sent to the ER for a UTI and then were later told that day by the Administrator that (R1) was sent out due to complaining of a stomach ache. The Administrator then indicated that (R1) was sent to the hospital in her primary medical group, when she was sent to another hospital in the area. One family member stated that no staff told her or her sister that (R1) had gone to the hospital. A second family member asserted “staff said they tried calling all of us but they did not leave any messages when (R1) was sent to the hospital”. One of the family members asserted that (R1) did not have a stomachache and was sent to the hospital they sent her to since it is a trauma center and (R1) hit her head. The other family member stated that at approximately 3:30pm on 4/27/23, the Administrator contacted (R1’s) other family member and asked her if she was going to pick up the “hard copy” prescription to get filled for the UTI. The Department received an incident report (LIC624), dated 4/27/23, which notes (R1) was sent to the ER on 4/26/23, at approximately 6:00 am by a non-emergency ambulance provider. The incident report notes that at approximately 6:00 am, (R1) had a “change in condition and was experiencing some discomfort” and was found on the floor by staff during room checks. It was decided to sent resident out for further medical evaluation. The LIC624 states that resident was taken to the assigned hospital through her health plan and that staff “contacted family” ; however, when the family member called (R1’s) assigned hospital, there was no record that (R1) had visited the night before. Hospital discharge papers confirm that (R1) was sent to another hospital other than her assigned primary care hospital and was seen for a fall and UTI and was prescribed Cephalexin (Keflex 500 mg) for (7) days. Charting notes from 4/26/23 document (R1) was sent to a different hospital than the one indicated on the LIC624. The Administrator later indicated to the family members that (R1) was sent to a different hospital in the area and it was not mentioned that (R1) was sent out due to a fall. It was discovered that (R1) had a UTI after being sent out for the fall. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. NOTE: A separate citation was not initially issued for this substantiated allegation but is being issued on a separate report, dated 10/4/23. cont on 9099C-4.. 90099C-4... Allegation: Staff did not give resident’s family copies of resident’s reports/documents upon request . Allegation reads that (R1)’s family members had a meeting with the Administrator, on 5/2/23, and requested to get a copy of the incident report as well as the Internal Occurrence Report for when (R1) went to the hospital on4/26/23 and copies of all incident reports since resident moved in. The Administrator agreed to provide these copies later in the day but was not able to locate them, and she said she did not have time to look for them. The RCC stated that she attended the meeting also on 5/2/23 and (R1's) family was provided with (1) incident report (LIC624) and (1) In-House incident report during the meeting. RCC stated she heard the Administrator agree to provide copies of all other LIC624's for (R1) and isn't sure if they were provided, but the Administrator was somewhat reluctant to do so. RCC stated that the incident from 4/26/23 is a separate one from the incident in (R1's) records that is documented in the charting notes and on an internal incident report from 4/28/23. (R1) was not sent to the ER on 4/28/23 after speaking with her family member. It should be noted that (R1) had began antibiotic treatment for a UTI following the visit to the hospital on 4/26/23 and could possibly have had a fall again on 4/28/23. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not ensure that the restroom emergency pull tab was functional . Complaint alleges that the pull cord in (R1's) restroom was not working from on/around February- May 2023 and was told that it had been fixed earlier than it actually was. Tour conducted on 5/12/23 -LPA tested the pull cord in (R1's) bathroom and observed it to light up as well as the pull-cord near (R1’s) bed. LPA tested the pull cord in a staff bathroom at 11:35 am and observed the red light to appear and tested a pull cord in a second staff bathroom and observed the light to appear at 11:45 am. LPA tested the pull cord in a second resident’s room and observed it to light up when activated. On 5/12/23, RCC showed LPA during the tour that this pull cord's location appeared on the monitor in RCC's office as having been pulled at the noted day/time and was "red" on the screen. The alert for (R1's) room appeared "purple" on the monitor in RCC's office. cont on 9099-C-5.. 9099C-5.. One family member stated on 7/26/23 the pull-cords were "non-functional" in (R1’s) bathroom from Feb 2023- May 2023 and she told the Administrator at the time, but they were not fixed timely. The same family member indicated she has "never seen a necklace or bracelet on (R1)".The Maintenance Director stated he wasn’t working at the facility from February-April 2023 and when he returned to the community on/around July 2023, he replaced all of the batteries to ensure all pull cords were working, both in resident rooms and staff areas. On 5/12/23, RCC stated a report for the response time was printed last week and that last week, not all pull cords were working but now they are working 100%. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not ensure that the resident restroom had paper products. Paper towels or wipes were not available in the resident restroom. LPA conducted a tour on 5/12/23 in (R1's) private bathroom. LA did not observe any paper towels or a paper towel dispenser in (R1's) shared bathroom. LPA observed (2) small cloth towels on a single towel rack. RCC stated on 5/12/23 that the facility fills each residents paper products in their individual bathrooms everyday and each resident receives 2 extra paper products On 9/26/23-LPA did not observe any towels, cloth or paper, to be in the bathroom. Administrator stated laundry was being done since (R1’s) laundry hamper was not in her room. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (6) citations are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... Allegation: Staff were not available and visible at the facility . Complaint alleges the Administrator at the time was informed on several occasion, at different times of the day, staff was not available, and at other times a staff member was not visible and able to be located. On 5/12/23 , RCC stated that during the AM shift there are 3 caregivers and 1 med tech on duty. RCC indicated that there are 10 staff on duty including house keepers during the AM shift. RCC stated that during the PM shift there are typically 3-4 caregivers and 1 med tech on duty. RCC stated that during the NOC shift there are 2 caregivers that are med tech trained. LPA has observed multiple staff on several visits made to the community from May- September 2023.n Additionally, the Ombudsman has made multiple visits to the facility and has not observed staffing to be insufficient. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not ensure that resident was properly dressed. Complaint states that during one visit, (R1) was wearing men’s pants that had an odor of urine; on another visit, (R1) was not wearing any undergarments, and on a third visit, (R1) was in the same clothes she was wearing the day before. LPA observed (R1) on 5/12/23 to be wearing a blue turtleneck sweater, pink bow in her hair, and to be sitting in her wheelchair. RCC showed LPA (R1’s) dresser and closet- LPA observed sufficient clothing and incontinent products on hand. On 7/31/23, LPA and one staff observed (R1) present in her room and to be dressed in clean, dry clothes with no incontinent odors noticed. LPA and the Administrator observed (R1) on 9/26/23 to be dressed in clean, dry clothing and wearing several bracelets. There were no incontinent odors observed Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099A-C-2... 9099A-C-2... Allegation: Staff did not ensure that resident had adequate bedding. During one of visits, (R1) only had one sheet and her personal lap blanket. Her feet had no socks and were ice cold. LPA conducted a tour on 5/12/23 and observed (R1's) bed to be made with (2) sheets and a blanket. An additional (3) crocheted blankets were folded on top of the bedspread. On 7/31/23, LPA observed a plastic protector on the mattress. (S2) showed LPA the different layers on the plastic protector- 1- cloth, 2- sheet, 4- cotton chuck, 5- disposable chuck. (S2) stated incontinent like 89% of the residents. AB stated all incontinent residents have both a cotton and disposable chuck on the sheets. (7) other resident rooms were inspected and all rooms were observed to have clean, dry linens on the beds with no significant incontinent odors present. On 9/26/23, LPA and Administrator observed (R1’s) bed to be made and all layers, sheets, incontinent pads and blankets to be clean and dry. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- Allegation: Staff did not ensure safe keeping of resident’s personal property. Missing items from (R1’s) room which include, slippers, jackets, plant and walker. During one of visits, (R1) was not in her wheelchair and was using a wheelchair with someone else’s name on it. When addressed, staff took her back to her room to switch wheelchairs and returned with a completely different wheelchair other than her own. On 5/12/23, RCC stated (R1's) daughter put a lock on her door. RCC stated she/Admin tell families that " it's Memory Care" and residents wander and things can disappear. RCC confirmed that R1 did have clothes missing and explained that there is a resident that likes to "shop" and goes in (R1's) room. On 7/26/23, R1’s family member stated that things disappear and some residents go in other residents' rooms, mentioning resident, ((R2), who takes items and exchanges them for cigarettes. On 9/26/23, another family member stated that RR has had bracelets stolen from resident, (R2) and "(R2) is a problem" as she has seen (R1's) things in (R2's) room. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to Administrator.